20797 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Preis Identification F PERMITNO.
Building Address:
Gt-3 (o o g f o� t�3 ► tt�tZ� �U 20797
�^1 _ cone:
C(7�O CITY OF CUPERTINO-BUILDING DIVISION
Mcan adoraName: Gc.No: APPLICATION /PERMIT "7
BUILDINGE.ECTRICA4PLUMBING.MECHANICAL CATEGORY CONTROL X
Architect/ gheer Lie.No:
QTY ELECTRIC PERMIT PEE BUILDING PERMIT INFO
Address: in q O &L PERMITISSUANCE IBL ❑ El
CONTRACTOR'S NATION u
I hereby affirm that l am Bcrosed under prev ons of Chapter 9(mmmenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
imgwith Sxrtmn7(X0)of Dwiamn3 ofthe Businessandifeulon.Code,and my
Iimmselslnfu0 odeffen. vnq PANELS
Licenre Claw J ont
C UP TO 2DO AMM
Date'?' Contractor O�
ARCHITECTS DECLARATION 701-1000 AMPS
0[-L I understand my plans shall be used as public records. OVERI000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
dF Licensed Professional SIGNSELECTRICAL
u� OWNER-BUILDER DECLARATION
E-n GTSPECIALCItCUIT/MLSC
Thereby offirm@atlam exempt from the Contractor's License hwfm the Feel
O Z F following reason.(Section 70315,Business and Professbm Code:Any city or TIME.METER OR POLE INST.
countywhlch requires a permit to construct,alter,Improve,denlolub,or repair
q Q nystructure prior to Its uauance,also requlresthe applicant for such Permit to POWEg DEVICES
F1 U file a signed statement that he u licensed pursuant to the provisions of the
Contractor's License (ChapterLaw 9(commencin ithSection 7000)ofDlvl-
E, g..3 ofthe Business and ProfebtuCode)orthaghe is exempt therefromand SWAIMINGIXJOL ELECfRIC VALUATION
<$ the basu for the allegedexemption. Any vlolalon of Section 7e315 by any OUTLEISSWITcHFs_FDcTuRES
applun mt fora permit aubjectsthe applicant to a civil penalty of not more tban
rive hundred dollars(5.500). NEW RESIDENTIAL ELECTR SQ.FT.
❑I,as owner of the property,or m employees with wages as their sole STORIES TYPE CONSTRUCTION
P Penta, Y employ g
7
compensation,KBusiness and randtbcs Code;Thure It e
Contraintenctors
orofferedLaw
O vie(Sec.7000,Business and Professions Code:The Contractors Lirense law
5 does not apply to an owner or property who a impar improvesded IN,and OCC.GROUP RIS.UNITS
whoovemnts am khlmselfedagbowne.If,ho eprovidedthatsuch
Improvements are net Intended earofcmotioned tarsale.If, ower-b the baldingve TOTAL:
improvementissold within oneyhe did otbuil porimthe,eforprose of ill sahave
mej L as o neerproing of the property,
a buildorimp contra ting with
Beans. QTY, PLUMBING PERMIT
u I,as owner of the property,am exclusively contracting with Licensed FLOOD ZINE APN
PERMIT ISSUANCE
contractors to construct the Project(Sec.7004,Business and Professions Code:
The Contractors License Taw does not apply to an owner of property who ALTER-DRAIN 6 VENT-WATER(EA)
Wilds or Improves thereon,and who comesets for such ptojern with a FEE SUMMARY
ro,NTactor(s)licensed pursuant to the Contractors License Law. BACK FLAW PROTECT.DEVICE
LI I am exempt under Sec B A P C for this reOUTSI FF FEES
ason DRMNSFLOORRODF,AREA,ODND. SANITARY Y_ N
Owner Date RECEIPT N
WORKMAN CSATION DECLARATION
F11have a mSCHOOL TAX Y_ N_
I hereby affirm that I have a certificate of conm seto self-Insure,or FIXTURES.PER TRAP RECEIPT N
ceftifIJhofWorkers'Comperuation Insurance or a certified copy tbemof(Sec' GAS EA.SYSTEM-1 INCAOLTLEfs , PARK FEE Y_ N_
U00,Policy N RECEIVI N
Com any GAS EA.SYSTEM-OVER4(EA) BUILDING DIVISION FEES
Certified copy is herebytumished' CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
F-1 Certified copy u filed with the city inspection division. P
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.70017. Date eceipttf
(This section need nut be completed ifthe permit is for one hundred dollars R
(E100)or less) WATER HEATER W/VENT/F1.ECTR ENERGY PEE Y_ N_
I certifym
that In the pedounce of thework forwhicb this permit is issued,
I shall not employ any person in any manner so as to became subject to the WATER SYSTEM/TREATING
Workers' ns
Compeation Laws of California.Date PAID
OApplicant - Date Recei tic
2 NEWRESIDENTIALPLMB. SQFf.
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Wor)ers''Compematlon provisions of the Lahor TOTAL:
CC W Code,you must forthwith comply with such provisions orthu permit shall be
W > BUILDING •E
deemed revoked.
CONSTRUCTION LENDING AGENCY r�y SEISMIC FEE
z
tl Ihereby affirm that there is a construction lending agency for the perform TOTAL: \—\ ELECTRIC FEE
Z .nee of the work for which this permit is Luued(Sec.3097,Civ.C.)
U O Lenders Name PLUMBING FEE
LL H Lenders Addrev QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U I certifythat l have read this application and tatethat the above Information
O W is correct.I agree to comply with all city and conte"miimances and tate laws PERMIT ISSUANCE FEES PAID:
r IL relating to building construction,and hereby authorize representatives of this
F" city to enter upon the above-mentioned property for Inspection pis rposes. ALTER OR ADD TO MECH.
Z
Date ReceiptN
V zga IBab�lliteiss,julgmxm e,� and xpmpisesawhich thermless City
anywaof yaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
aga t said City I n of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
S' natureof Applicant/Contractor Date EXHAUST HOOD BY/DUCp CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store orhandle hacardess HEATING UNIT(TO 100,000 BTU) Date ReCel tic
materlal as defined by the Cupertino Municipal Code,Chapter 9.12 and the
IfealthanciSafety Code Section75537(a)7 HEATING UNIT(OVER 10[,000 BTU) O
F-1 _ TOTAL:
Yes r]No O
Will the applicant or future Wilding occupant use equlpment or devices VENTILATION FAN(SINGLE RESID) ISSU 1_f ATE
which emit hard rdous air rants oneants as defiled by the Bay Area Air
Quality Maragetrent District? BOILER-COMP OIL'OR 100,M BTU)
qYes [] o
have reidthehav'�3 smateriaurequimm nuunderCbapter6.95of BOILER-COMP(OVER 100,0D0 BTU)
the California Ileeth A Safety Code,Sectioan 5505,75533 and 25534.1
understand that ifthe building don not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFf
nsmfilym n fythe amt of the requncments which must be met City Cf rUCgpflCp
Ari to issuance aCe I eof Omu zncy.
mer ora orized agent Date TOTAL: ISSUEDBY:
OFFICE COPY